Transcript Evidence-based Diabetes Prevention – National Policy Considerations Ronald T Ackermann, MD, MPH, FACP Diabetes Translational Research Center Indiana University School of Medicine.

Evidence-based Diabetes
Prevention – National Policy
Considerations
Ronald T Ackermann, MD, MPH, FACP
Diabetes Translational Research Center
Indiana University School of Medicine
Continuum of Risk & Intervention
200 Million with Obesity
Risk Factors?
140 Million
Overweight or
Obese*
85 Million
High Risk
for Diabetes
Diabetes,
Heart
Disease,
Stroke
Population-based Policies
(Social/Cultural Change)
Long-term Payoff
Resource Intensive Programs
(Prevent Obesity-Related Risks)
Shorter-term Payoff
* Estimated from Flegal KM, et al. JAMA. 2010;303(3):235-241.
† Using ADA prediabetes definition OR A1c 5.7-6.4%; Source: NHANES 2005-06
U.S. Diabetes Prevention Program
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National comparative effectiveness trial
3,200 overweight / obese adults with prediabetes
Compared 3 preventive interventions
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Lifestyle Program most effective
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Brief Education (usual care)
Diabetes Pill Metformin
Intensive Diet & Physical Activity Program
Prevented 58% of new diabetes cases
Worked for all age, gender, and race subgroups
Replicated worldwide – 6 studies; >5,400 total participants
* DPP Research Group. N Eng J Med 2002;346(6):393-403.
DPP Lifestyle Program
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16-session course over 24 weeks; then monthly
One-on-one personal coach format
Goal to lose/maintain ≥7% of body weight
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Cut down dietary calories & fat
≥150 min/week moderate physical activity
Education & training in behavior modification (Selfmonitoring; problem solving)
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Strong support structure (building self esteem,
empowerment, social support; accountability)
DPP: Modest Weight Loss is the Goal
In DPP…
…every 1 kilogram of weight loss =
16% decrease in chances of getting diabetes
…just 5 kg (11 pounds) of weight loss =
58% decrease in chances of diabetes
+
*Hamman, et al. Diabetes Care 2006; 29:2102–2107.
DPP Lifestyle Program Summary
Treating 100 high risk adults (age 50) for 3 years…
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Prevents 15 new cases of Type 2 Diabetes1
Prevents 162 missed work days2
Avoids the need for BP/Chol pills in 11 people3
Avoids $91,400 in healthcare costs4
Adds the equivalent of 20 perfect years of health5
1 DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403
2 DPP Research Group. Diabetes Care. 2003 Sep;26(9):2693-4
3 Ratner, et al. 2005 Diabetes Care 28 (4), pp. 888-894
4 Ackermann, et al. 2008 Am J Prev Med 35 (4), pp. 357-363; estimates scaled to 2008 $US
5 Herman, et al. 2005 Ann Intern Med 142 (5), pp. 323-32
DPP Dissemination Challenges
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Too costly ($1,800+) in year 1 alone
Intense & long-term – skepticism over
replication in the ‘real world’
IUSM’s Approach for DPP Translation
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Stick to the DPP approach
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Goal-oriented; weight loss through diet & exercise
Target adults at highest risk for diabetes now (prediabetes)
Adopt “practical” solutions for key barriers
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Minimize intervention costs
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Group-based delivery
Strong, not-for-profit community partner
Preserve effectiveness (weight maintenance)
DEPLOY1, DPP-LINC2, & RAPID3 Studies
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Community comparative effectiveness trials
Group DPP at the YMCA vs. standard advice
~70% of high risk adults with pre-diabetes attend the
YMCA at least once if referred4
Average weight loss among those attending YMCA at
least once 5.0% to 6.8%5
Weight losses still 4.8% after 28 months6
Cost of YMCA DPP delivery ~$240 in year 1
1
R34-DK070702 (NIH); 2 R34-DK071527 (NIH); 3 R18-DK079855 (NIH)
4 Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63; RAPID study ongoing (unpublished)
5
Ackermann, et al. DPP-LINC Study Results, under review 07/2010
DEPLOY Extension Study results under review 07/2010
6 Long-term
Recipe for Successful Scaling
Right People
High risk for
short-term
obesity-related
problems
(Pre-Diabetes)
Right
Interventions
Intensive &
ongoing (DPP)
Scalable
Delivery
Model
Nationwide
CostEffective
Population
Based
Prevention
Valued Health
Outcomes
Accessible
Lifelong diet &
activity changes
Achieves modest
weight loss
Coordinated
with Medical
Home
Sustainable to
Finance
Supportive Policy Actions Still Needed
Step in the Process
Target(s)
Supportive Policy
Whole population focus on
better health
HHS; States;
Others
New policies to make healthy eating & activity desired,
normative, convenient, & feasible ($)
People seek testing/resources CDC; ADA
Raise awareness of risk factors; how to be tested
Clinicians test & offer
resources
CMS; NCHS
Revise ICD/HCPCS to easily document tests/counseling
USPSTF
Revisit recommendation for targeted screening
NCQA
Develop performance indicators for testing/referral
CMS; payers
New coverage policies to expand testing (A1c); payment
policies to reward providers
Programs available
HHS; CDC
Develop workforce; recognize community programs that
are ‘evidence-based’
Programs accessible
CPSTF
Review / recommend community-based DPP
CMS; payers
Review coverage policies for community-based
prevention services by recognized CBOs
NCQA
Review/recommend as part of PCMH Recognition
CMS; payers
New payment policies for CBO referral/feedback
Coordination with medical
home